Provider Demographics
NPI:1841820040
Name:AMUNDSEN, STEPHANIE ELIZABETH (CCC-SLP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ELIZABETH
Last Name:AMUNDSEN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17872 CHEROKEE DR
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-9404
Mailing Address - Country:US
Mailing Address - Phone:616-502-5756
Mailing Address - Fax:
Practice Address - Street 1:2885 10 MILE RD NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-9177
Practice Address - Country:US
Practice Address - Phone:616-326-0010
Practice Address - Fax:616-326-0011
Is Sole Proprietor?:No
Enumeration Date:2020-01-16
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101006303235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist